L22 - Eye movement disorder (LA)

Question 1

Diplopia

Answer 1

Double vision

Question 2

a) Ocular myasthenia?
b) What happens when it is systemic?
c) What is it treated by?
d) How is the post-synaptic membrane affected?

Answer 2

a) Autoimmune disorder where AchR on the extraocular muscles are attacked by the immune system, leading to fatigue (hence droppy eye and no eye muscle movement)(most common area being the EOM/levator)
b) When systemic (myasthenia gravis) - if muscles of swallowing or breathing are affected (aka myasthenic crisis) hence why dsyphagia (difficulty swallowing) can be a sign of myasthenia gravis
c) Treated with tensilon (edrophonium), a short acting anticholinesterase where administration fixed droppy eye and eye movement
d) Folds (usually deep and full of ACh-esterase which breaks down ACh) are shallower and Ach-esterase is closer to Ach receptors (inactivating Ach as soon as it is released)

Question 3

T/F - In ocular myasthenia, saccades may appear to be overly fast or slow

Answer 3

T

Question 4

Internuclear opthalmoplegia (INO)

Answer 4

Damage to the medial longitudinal fasciculus

If it is interrupted then the left eye can still abduct (look to the left) but the right eye cannot adduct (cannot look to the left).

Question 5

Medial longitudinal fasciculus location and what is it vulnerable to?

Answer 5

Runs from interneurones in the abducens (6th nerve) nucleus in the pons up to the oculomotor (3rd nerve) nucleus in the midbrain, crossing the midline as it goes to the other eye.

It is vulnerable to disease (MS in particular)

Question 6

Yoke?

Answer 6

To put to work

Question 7

Nystagmus (invol. eye movement) in abducting eye - general idea is that one eye is not adducting causes the other abducting eye to overshoot (this leads to double vision) but they eventually get on target

Answer 7

Nystagmus (invol. eye movement) in abducting eye - general idea is that one eye is not adducting causes the other abducting eye to overshoot (this leads to double vision) but they eventually get on target

Question 8

Commonest causes of INO? How about in older patients? What happens if lesions are large enough?

Answer 8

MS - MLF is a site for a demyelinating plaque

Stroke or tumour in older patients

Vergence can also be affected as well as adduction

Question 9

T/F - In INO, Vergence can also be affected as well as adduction

Answer 9

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Question 10

T/F - In INO you may still converge (move eyes towards the middle)

Answer 10

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Question 11

Misdirection syndromes

Answer 11

Sometimes nerves get crossed, either at birth or later, as a result of trauma

Question 12

Duane’s congenital retraction syndrome - what is it? How does one get it?

Answer 12

Benign condition where the hallmark is a unilateral or bilateral abducens palsy (limited abduction)- often, attempted adduction leads to a retraction of the affected eye into the orbit

Loss of 6th nerve - The 3rd nerve knows the lateral rectus is not innervated (when 6th nerve is absent) - 3rd nerve also innervates it, hence retracting eye back into the orbit

Question 13

When a nerve is damaged by trauma - the nerve tries to repair things by sprouting new fibres BUT it may not connect where it should e.g. Aberrant regeneration of the 3rd nerve which leads to?

Answer 13

The eye doing the opposite or irrelevant action e.g. 3rd and 6th nerve get mixed so while looking at right, left eye responds with abduction

Question 14

Nystagmus - what is it and how is it treated?

Answer 14

Ocular oscillation initiated by a slow movement of the eyes off-target - most often followed by a fast eye movement bringing them back towards the desired point of fixation

Either treated by surgery or using prisms in glasses

Question 15

Oscillopsia

Answer 15

Objects in the visual field appear to oscillate. The severity of the effect may range from a mild blurring to rapid and periodic jumping

Question 16

!T/F - In congenital nystagmus, it is primarily uniplanar - usually horizontal and stays that way no matter where the patient looks

Answer 16

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Question 17

Why can someone with nystagmus have 6/6 vision?

Answer 17

Due to the long and common foveation periods

Question 18

People with social phobia do not focus on the eyes and nose (like normal people), they look everywhere around the face without fixating for long periods.

Sometimes scanning is not normal

Sometimes scanning is fine, but cannot recognise emotion

Answer 18

People with social phobia do not focus on the eyes and nose (like normal people), they look everywhere around the face without fixating for long periods.

Sometimes scanning is not normal

Sometimes scanning is fine, but cannot recognise emotion

Question 19

How does Alzheimer’s disease affect how we process novelty?

Answer 19

They fail to respond to novelty and have diminished visual curiosity - only looking at the kid but not the bipedal horse

Question 20

Ventral simultanagnosia

Answer 20

Able to see several objects at once, but their recognition of objects is piecemeal, or limited to one object at a time. Thus, individuals with ventral simultanagnosic symptoms are capable of navigating through a room without bumping into furniture.

• Colour vision is normal - can identify the colour plate but cannot integrate the information and identify the number
• Visual system could drive action e.g. gaze but without perception

Question 21

Dorsal simultanagnosia

Answer 21

Perception is limited to a single object without awareness of the presence of other stimuli. Thus, being able to see only one object at a time, a patient may collide with various objects in a room being unaware of them. Additionally, objects in motion appear more difficult to perceive

Question 22

What is more severe, ventral or dorsal simultangonisa?

Answer 22

Dorsal simultagnosia - they can see the trees but not the forests. Another example is like drawing a H outline with circles and only identifying the O-letter but not the H

Question 23

!What are the two most common types of Congenital Nystagmus?

Answer 23

1) Jerk CN - jerk with extended foveation

2) Psuedo-cycloid - the fast phase doesn’t bring the eyes back to target, a slow eye movement does